Provider Demographics
NPI:1316993256
Name:SSM REGIONAL HEALTH SERVCIES
Entity type:Organization
Organization Name:SSM REGIONAL HEALTH SERVCIES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN CONIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-761-7000
Mailing Address - Street 1:PO BOX 1027
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65102-1027
Mailing Address - Country:US
Mailing Address - Phone:573-761-7246
Mailing Address - Fax:573-761-6947
Practice Address - Street 1:2265 BAGNELL DAM BLVD
Practice Address - Street 2:STE 103
Practice Address - City:LAKE OZARK
Practice Address - State:MO
Practice Address - Zip Code:65049-8603
Practice Address - Country:US
Practice Address - Phone:573-365-6800
Practice Address - Fax:573-365-6011
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SSM REGIONAL HEALTH SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-25
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO507349108Medicaid
MO507349108Medicaid